Sunday, 24 November 2013

Pleural disease – Pleural effusion – The Causes

The pleura is a thin tissue covered by a layer of cells (mesothelial cells) that surrounds the lungs and lines the inside of the chest wall.
B. Pleural effusion
It is a condition of collection of fluid within the pleural cavity as a result of heart failure, bleeding (hemothorax), infections, excessive or decreased fluid volume, etc.
B.2.1. Causes
1. Congestive heart failure
In the study to determine the distribution of pleural effusion between the right and left hemithorax in patients with uncomplicated congestive heart failure, and whether left-sided pleural effusion actually constitutes an atypical distribution in congestive heart failure, indicated that there were bilateral pleural effusions of roughly equal size on each side in 36, there were bilateral pleural effusions larger on the left side than the right in 26, and there were isolated left-sided pleural effusions in 15. The difference was not statistically significant (chi2 = 0.316; P < or = 1.0)(18).
2. Pneumonia
According to the Universidade Federal do Espírito Santo, Vitória, in a a retrospective observational study involving 121 patients with CAP/PPE hospitalized in a tertiary referral hospital between 2000 and 2008, the prevalence of M. pneumoniae-related CAP/PPE was 12.75%. Although the disease was milder than that caused by other microorganisms, its course was longer. Our data suggest that M. pneumoniae-related CAP and PPE in children and adolescents should be more thoroughly investigated in Brazil(19).
3. Liver disease (cirrhosis) and chronic renal disease
There is a report of a 59-year-old man treated with hemodialysis for liver cirhhosis and chronic kidney disease developed right pleural effusion and ascites, according to the study by Takasago Municipal Hospital(20).
4. Primary systemic amyloidosis
According to the study by the Boston University School of Medicine, large, recurrent pleural effusions in systemic amyloidoses are rare but clinically challenging events predominantly affecting patients with primary systemic amyloidosis(21).
5. Nephrotic syndrome
Nephrotic syndrome is a condition of kidney damage with symptoms of protein in the urine, low blood protein levels, high cholesterol levels, high triglyceride levels, etc. According to the study by the, The occurrence of the nephrotic syndrome during mycosis fungoide is very unusual, but there is a report of a rare case of mycosis fungoide revealed by hydrops related to nephrotic syndrom in a 37-year old male patient. He has been admitted to intensive care unit because of a breathing distress and a hydrophobs. Whole body computed tomography scan revealed bilateral axillary, cervical lymph nodes, tumoral infiltration of the subcutaneous tissue in the cervicothoracic and abdominal regions, multiples bilateral pulmonary metastasis, bilateral pleural effusion, and abdominal effusion; the kidneys were normal(22).
6. Surgery
There is a report of 2 cases with unusual "complications" after pacemaker implantation. One patient developed hemorrhagic pleural and 1 patient pericardial effusion. Both manifestations of hemorrhage were felt to be due to complications in relation to the pacemaker implantation(23).
7. Tumors
According to the study by the, Pneumothorax and pleural effusion can occur after radiofrequency (RF) ablation in patients with lung tumors(24).
8. Pulmonary embolism
There is a report of a case of hypertensive 58-year-old woman with hepatic nodules presented dyspnea and pleural effusion one week after an episode of pulmonary embolism(25).
9. Lupus
In the prospective study of 54 patients with pleural effusion (12 lupus pleuritis, seven parapneumonic effusion, 26 malignancy-associated pleural effusions, nine transudative effusions) was performed. ANA at a titer of ≥1, 160 were found in 11 of 12 lupus pleuritis samples, and in four of 42 pleural effusions from non-systemic lupus erythematosus (SLE) patients. The pleural effusion ANA at a titer of ≥1, according to the study by Chiang Mai University(26).
10. Systemic diseases
Despite the low incidence (around 1%) of pleural effusions caused by systemic diseases, more often connective tissue diseases, such as rheumatoid arthritis or systemic lupus erythematosus, may present with this(27)
11. Infections
In the study to investigate whether pleural fluid concentrations of biomarkers for bacterial infection, namely triggering receptor expressed on myeloid cells (sTREM-1), procalcitonin (PCT), lipopolysaccharide-binding protein (LBP) and C-reactive protein (CRP), might identify infectious effusions and discriminate between complicated (CPPEs) and uncomplicated parapneumonic effusions (UPPEs) with Stored pleural fluid samples from 308 patients with different causes of pleural effusion were used to measure the four biomarkers indicated that the area under the curve for distinguishing infectious (parapneumonics and tuberculosis) from noninfectious effusions was 0.87 for CRP, 0.86 for sTREM-1, 0.57 for PCT and 0.87 for LBP. Regarding the discrimination of nonpurulent CPPE versus UPPE, a multivariate analysis found that pleural fluid glucose or =17 microg x mL(-1) and CRP > or =80 mg x L(-1) were the best parameters. Individually, none of the new biomarkers achieved better performance characteristics than pH, glucose or lactate dehydrogenase in labelling CPPE(27a).
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